A home health nurse is assessing a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?
Reinforce the importance of daily weights.
Call the health care provider for further instructions.
Document the findings and continue with the visit.
Ensure the client has been taking their prescribed diuretic.
The Correct Answer is D
A. Reinforce the importance of daily weights. While reinforcing the importance of daily weights is crucial for managing heart failure, it does not address the immediate concern of the patient's weight gain and edema. The nurse needs to take a more direct action to manage the patient's current condition.
B. Call the health care provider for further instructions. Calling the health care provider is a reasonable step, but it may delay immediate intervention that the nurse can perform. Ensuring the patient is taking their prescribed diuretic can provide more immediate relief from fluid retention.
C. Document the findings and continue with the visit. Documenting the findings is necessary for accurate medical records, but it does not address the urgent need to manage the patient's symptoms. Immediate action is required to prevent further complications.
D. Ensure the client has been taking their prescribed diuretic. Ensuring the patient has been taking their prescribed diuretic is the most appropriate immediate action. Diuretics help reduce fluid buildup, which can alleviate the weight gain and edema, providing quick relief and preventing further complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. While this may be relevant information, it is not directly related to the Health Belief Model, which focuses on individual beliefs and attitudes about health behaviors.
B. This aligns with the Health Belief Model, which emphasizes the importance of social influences and support in health-related decision-making.
C. This is a valid point, but it does not directly relate to the Health Belief Model.
D. This is a policy-based approach and does not directly relate to the Health Belief Model.
Correct Answer is ["0.5"]
Explanation
To calculate the number of tablets the nurse should dispense to the client, we need to convert the prescribed dose of digoxin from milligrams (mg) to micrograms (mcg), as the tablets are labeled in milligrams.
1 mg = 1000 mcg
125 mcg = (125 mcg) / (1000 mcg/mg) = 0.125 mg
Now, we can determine the number of tablets needed to achieve this dose:
0.125 mg ÷ 0.25 mg/tablet = 0.5 tablets
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